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Laboratory Request Form Laboratory Request Form: Diagnosis: Diagnosis

This document is a laboratory request form containing a patient's name, date, and gender as well as boxes to check for various lab tests including a CBC, lipid profile, liver function tests, thyroid panel, urinalysis, electrocardiogram, x-rays, and ultrasound. It also includes spaces for the diagnosing physician's name, license and PTR numbers, and signature.

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ActiveOne Health
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6K views1 page

Laboratory Request Form Laboratory Request Form: Diagnosis: Diagnosis

This document is a laboratory request form containing a patient's name, date, and gender as well as boxes to check for various lab tests including a CBC, lipid profile, liver function tests, thyroid panel, urinalysis, electrocardiogram, x-rays, and ultrasound. It also includes spaces for the diagnosing physician's name, license and PTR numbers, and signature.

Uploaded by

ActiveOne Health
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Patient’s Name: Patient’s Name:

Age: Gender: Date: Age: Gender: Date:

LABORATORY REQUEST FORM LABORATORY REQUEST FORM

CBC PERIPHERAL BLOOD SMEAR CBC PERIPHERAL BLOOD SMEAR


FBS ALKALINE PHOSPHATASE FBS ALKALINE PHOSPHATASE
HbA1C HbA1C
LIPID PROFILE TSH LIPID PROFILE TSH
ALT/SGPT T3 ALT/SGPT T3
AST/SGOT T4 AST/SGOT T4
BLOOD URIC ACID BLOOD URIC ACID
BUN HBSAg (Screening/Titer) BUN HBSAg (Screening/Titer)
CREATININE CREATININE
CHOLESTEROL URINALYSIS CHOLESTEROL URINALYSIS
SODIUM SODIUM
POTASSIUM 12 L-ECG POTASSIUM 12 L-ECG

XRAY: XRAY:
ULTRASOUND: ULTRASOUND:
OTHERS: OTHERS:

DIAGNOSIS: DIAGNOSIS:

________________________________, MD ________________________________, MD
Lic. No.______________________________ Lic. No.______________________________
PTR. No._____________________________ PTR. No._____________________________
S2 No._______________________________ S2 No._______________________________

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